Acute ischemic stroke due to Electrical Injury: A case report

Debapriya Ghosh1, Adarsh Nath2, Suhas Sagar N.U3

1, 2MEM Resident – Kauvery Hospitals, Bengaluru

3Consultant – Emergency Medicine, Kauvery Hospitals, Bengaluru

Background

The growing dependence on electricity in our daily lives has increased the incidence of electrical injuries and are most commonly accidentally incurred. The severity of injury depends on the type and strength of current and ranges from a barely perceptible tingling sensation to instant death.

Eventhough, several neurological injuries have been described before, acute stroke due to electrical injuries is only reported in a handful of cases, as only nine cases are published in English Literature (1)

Case Presentation

A 27 years aged Male patient was presented to ED with a h/o sustaining an electrical injury through the wall socket when he was about to plug in his phone charger, with c/o left sided weakness; LL>UL, associated with headaches.

  • A – No known allergies.
  • M – Foracort/ Rotacaps inhalers SOS.
  • P – Bronchial Asthma.
  • L – 20:00 hours (dinner).
  • E – As described.

On Examination

  • A – Patent
  • B – RR: 18/min, SpO2: 99% RA
  • C – HR: 82/min, BP: 140/86 mmHg
  • D – GCS: E4M6V5, Pupils: BERL (3mm)
  • E – Entry wound in left elbow, exit wound in left second toe

The GS of Primary Survey

  • CBG: 128 mg%
  • VBG: mild metabolic acidosis with lactates of 3.4
  • EKG: sinus tachycardia
  • USG: No RWMA, EF: 60%, No free fluid in abdomen.

Secondary Survey

Conscious, Oriented to time/place/person

  • Pupils: BERL (3mm)
  • EOM: full, No nystagmus, Vision 6/6 bilateral
  • Power: Right upper and lower limbs; 5/5, Left upper limb; 3/5, left lower limb; 0/5. Gait could not be assessed.
  • NIHSS: 07/43

Secondary Survey adjuncts

MRI Brain with MR Angiogram- Diffusion flair mismatch suggesting in window stroke for thrombolysis.

Findings

Fig (1-3): MRI Images

Interventions

Patient underwent intravenous thrombolysis with Tenecteplase 20mg (0.25mg – 80kg) in ER, after ruling out contraindications for thrombolysis. Patient had significant improvement post thrombolysis with right upper limb power 4/5 and lower limb power 3/5 within 2 hr of thrombolysis.

Clinical outcome

After a month, post neuro rehabilitation and physiotherapy patient is able to walk without support and has full power in limbs.

Discussion

Blood vessels, due to their high water content, can transmit electric current easily to distant sites and cause metastatic injuries. In animal models, direct electrical stimulation of cerebral vessels can cause vasospasm and this effect has been seen at distant sites [2]. In a study looking at vascular injuries due to electrocution in humans, vasospasm was seen in 8 of 12 patients on angiogram [3].

Electrostatic energy in blood vessels can initiate vascular mediopathy and/or intravascular coagulation even when the surrounding tissues appear to be normal[4]. In fact, electricity is used for thrombus generation in animal models when studying carotid artery clots [5].

Acute stroke is also described in electric injury due to lightning [6]. The low-voltage current-induced vasospasm rather than direct vascular injury, and this may explain why the intracranial defect occurred away from the electrical current pathway.

Conclusion

Electric shock injury with low-voltage alternating currents and prolonged contact period may cause ischemic stroke.

References

  • http://www.cdc.gov/niosh/docs/98-131/pdfs/98-131.pdf.
  • Chen W.-H., Chui C., Lui C.-C., Yin H.-L. Ischemic stroke after low-voltage electric injury in a diabetic and coagulopathic woman. Journal of Stroke and Cerebrovascular Diseases. 2012;21(8):913.e1–913.e4. doi: 10.1016/j.jstrokecerebrovasdis.2011.12.009. [PubMed] [CrossRef] [Google Scholar]
  • Echlin F. A. Vasospasm and focal cerebral ischemia an experimental study. Archives of Neurology & Psychiatry. 1942;47(1):77–96. doi: 10.1001/archneurpsyc.1942.02290010087007. [CrossRef] [Google Scholar]
  • Hunt J. L., McManus W. F., Haney W. P., et al. Vascular lesions in acute electric injuries. Journal of Trauma—Injury, Infection & Critical Care.1974;14(6):461–473. doi: 10.1097/00005373-197406000-00003. [PubMed] [CrossRef] [Google Scholar]
  • Kusada A., Isogai N., Cooley B. C. Electric injury model of murine arterial thrombosis. Thrombosis Research. 2007;121(1):103–106. doi: 10.1016/j.thromres.2007.03.005. [PubMed] [CrossRef] [Google Scholar]
  • Cherington M., Yarnell P. R., London S. F. Neurologic complications of lightning injuries. Western Journal of Medicine. 1995;162(5):413–417. [PMC free article] [PubMed] [Google Scholar.

Dr. Suhas Sagar N.U
Consultant – Emergency Medicine

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